title: Adjuvant intravesical bacillus calmette-guérin therapy and survival among elderly patients with non-muscle-invasive bladder cancer.
abstract: OBJECTIVE
  National guidelines recommend adjuvant intravesical Bacillus Calmette-Guérin (BCG) therapy for higher-risk non-muscle-invasive bladder cancer (NMIBC). Although a survival benefit has not been demonstrated, randomized trials have shown reduced recurrence and delayed progression after its use. We investigated predictors of BCG receipt and its association with survival for older patients with NMIBC.
  
  
  METHODS
  We identified individuals with NMIBC registered in the Surveillance, Epidemiology, and End Results-Medicare database from 1991 to 2003. We used logistic regression to compare those treated with BCG within 6 months of initial diagnosis with those not treated, adjusting for demographic and clinical factors. Cox proportional hazards modeling was used to analyze the association between BCG and overall survival (OS) and bladder cancer-specific survival (BCSS) for the entire cohort and within tumor grades.
  
  
  RESULTS
  Of 23,932 patients with NMIBC identified, 22% received adjuvant intravesical BCG. Predictors of receipt were stages Tis and T1, higher grade, and urban residence. Age > 80 years, fewer than two comorbidities, and not being married were associated with decreased use. In the survival analysis, BCG use was associated with better OS (hazard ratio [HR], 0.87; 95% CI, 0.83 to 0.92) in the entire cohort and BCSS among higher-grade cancers (poorly differentiated: HR, 0.78; 95% CI, 0.72 to 0.85; undifferentiated: HR, 0.66; 95% CI, 0.56 to 0.77).
  
  
  CONCLUSIONS
  Despite guidelines recommending its use, BCG is administered to less than one quarter of eligible patients. This large population-based study found improved OS and BCSS were associated with use of adjuvant intravesical BCG among older patients with NMIBC. Better-designed clinical trials focusing on higher-grade cancers are needed to confirm these findings.
authors.affiliation: Columbia University, New York, USA. bas10@columbia.edu
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Spencer
authors.forename: Russell B
authors.initials: RB
authors.lastname: McBride
authors.forename: Dawn L
authors.initials: DL
authors.lastname: Hershman
authors.forename: Donna
authors.initials: D
authors.lastname: Buono
authors.forename: Harry W
authors.initials: HW
authors.lastname: Herr
authors.forename: Mitchell C
authors.initials: MC
authors.lastname: Benson
authors.forename: Supriya
authors.initials: S
authors.lastname: Gupta-Mohile
authors.forename: Alfred I
authors.initials: AI
authors.lastname: Neugut
mesh_terms: D000276:Adjuvants, Immunologic / Q000008:administration & dosage*; D000283:Administration, Intravesical; D000368:Aged; D000369:Aged, 80 and over; D001500:BCG Vaccine / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D008297:Male; D018426:SEER Program; D016019:Survival Analysis; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy*
chemical_list: D000276:Adjuvants, Immunologic; D001500:BCG Vaccine